When a pharmacist — for personal beliefs — refuses to fill a prescription, the health plan should be very concerned.

Michael S. Victoroff, MD

The reason we evolved with two ears is because we survive better if we can hear two sides of an argument. This talent comes in handy in analyzing the ruckus over pharmacists refusing to provide emergency contraception.

A story out of Illinois presents a case where a pharmacist, citing "religious values," declined to dispense morning after pills (MAPs) to a woman with a valid prescription. Elsewhere, a pharmacist confiscated a woman's MAP prescription and refused to return it. These stories were augmented by reports of pharmacists refusing to fill prescriptions for birth control pills (a different issue, confusing to the uninformed). The New York Times noted 180 reports of pharmacists withholding MAPs or BCPs, nationwide, over a six-month period in 2004. The Times attributed this to "religious conservatism."

Health care organizations are vulnerable to entanglement when members get ambushed by ideological conflicts of interest. Thoughtful organizations need policies to reduce disruption from encounters of this sort. When can pharmacists inject moral values into their practices, and how should the health system respond when they do?

Let's skip the unconstructive solution of installing vending machines, or imposing mindless guidelines that amount to the same thing. A ton of literature supports a role for pharmacists intervening to rescue patients from prescribing blunders. (OK, this is somewhat offset by dispensing blunders, but, the balance favors intervention.)

A police matter

And ignore the pharmacist who confiscated the MAP script. That was simply theft. The victim should have called the police and had him arrested like any mugger. The problem is when the pharmacist hands back the script and says, "I don't believe in that; go away."

It's proper for pharmacists not to dispense in some circumstances, like interactions. Even if you were programming an ATM, you would sometimes want it to withhold a medication. The question is, aside from evidence-based, safety concerns, how do we feel about pharmacists with moral reservations about certain medicines?

Professionals commonly abstain from procedures on ethical grounds. Contraception is on a long list with circumcision, cosmetic surgery, IUDs, abortion, fetal reduction, futile and non-evidence-based therapy, "spiritual healing," electroconvulsive therapy, assisted reproduction, assisted suicide, capital punishment, and torture. Some things are even addressed in professional codes.

Prisoners of conscience

The American Pharmaceutical Association says, "APhA recognizes the individual pharmacist's right to exercise conscientious refusal and supports the establishment of systems to ensure patient access to legally prescribed therapy without compromising the pharmacist's right of conscientious refusal."

World peace is nice, too. But, this fence-straddling "conscience clause" doesn't explain how to keep some people from becoming prisoners of other people's consciences.

When a pharmacist withholds a prescription because of medical risk, the beneficiary is the patient. When a pharmacist refuses on grounds of moral disapproval, it's the pharmacist who benefits. I flatly dismiss the tautological argument that moralistic intervention benefits the party being "saved from sin." Some people thought burning was good for the witches, but it wasn't.

Refusing to fill a narcotic prescription for an abuser is part of the therapy. But, a pharmacist who refuses Ritalin to a hyperactive 6 year-old because "his yoga instructor doesn't believe in it" is guilty of a boundary violation. There is a distinction between objective benevolence and self-indulgent intolerance. Conscience looks inward; zealotry only looks out.

Some who were outraged by the Taliban pharmacist appealed to the notion of some social covenant to yoke him to community mores. They suggested that compliance was an implied condition of his licensure, or maybe the pharmacy's.

However, neither the store nor its personnel are obliged to sell specific products, whether they be MAPs, cigarettes, or Playboy magazines. There is a version of the "social contract" argument that applies to hospitals providing ER services, but it doesn't carry over to community pharmacies, most of which aren't even open round the clock.

Obligation to disclose

Nevertheless, I would argue there is an ethical duty to disclose eccentric policies. Imagine a "Jehovah's Witness Blood Bank." (They have plenty of blood, but you can't have it.) This would not resonate with reasonable expectations. Such an extreme violation of norms would be inherently unethical. A pharmacy that foreseeably plans to frustrate the public is obliged to publicize this.

It should also look for a workaround. The "cake-and-eat-it-too" solution would be to arrange alternative coverage to insure patrons full service while indulging conscientious objectors.

Oregon's Death with Dignity Act respects professionals who don't want to be associated with suicide. The law never would have passed otherwise. Of course, folks with hemlock scripts have time to hunt for a vendor. MAPs need to be taken right away, so women with geographic constraints have a problem. News stories did not indicate whether the MAP cases involved true geophysical hardship, or merely patrons dismayed by inconvenience.

This is an important detail, because a real conflict of interest requires a barrier to care, not just a contest of ideologies. Indignation rings hollow with a competitor across the street.

I can't help contrasting the flap over another pharmaceutical news bite: Public funding of erectile dysfunction drugs for male sex offenders. Many folk outraged over pharmacists interfering in women's sex lives saw no contradiction in messing with men's.

All that being said on the side of liberty, there has to be balance. Unlimited pharmacist discretion means no protection from bigotry. Religious principles are capable of malignant transformation into fundamentalist demagoguery. What if a pharmacist would not serve women except if they wore head scarves? Or, if an optometrist withheld eyeglasses because women have no need to read?

We tolerate diverse values in our society because diversity itself is a value — and they usually don't cause much fuss. Tolerance makes peace, but there can be bloody war when ideologies turn political. For examples, see world history since 50,000 B.C.

Commerce is the key

The golden idol, "religion," is invoked to justify acts across the moral spectrum. Some champions of religious freedom mistake it for the license to impose dogma on others. But, there's a big difference between self control and social control.

In our democracy, the best way to rein in ideogogues is through commerce. Managed care organizations, like most of their subscribers, have an interest in supporting full service providers, and marginalizing restrictive ones. The most effective strategy for reducing ideological conflicts is not to patronize folks who cause friction. This formula applies to all kinds of business, including HMOs and auto companies. It's Adam Smith, the freedom fighter. Let's have some pressure from contractors to secure pharmacy services across the broadest range of needs.

Michael S. Victoroff, MD, is a family practitioner and ethicist in Denver who has also been an HMO medical director. He reports no conflicts of interest in relation to his column in Managed Care.

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